Beaver Dam Nursing & Rehab Center, Inc

In the surveyor’s words

From the most serious findings on record at Beaver Dam Nursing & Rehab Center, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF657Aug 5, 2022

  Based on interview, record review, review of the facility's policy and the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, revised [DATE], it was determined the facility failed to revise the Comprehensive Care Plan with interventions to treat pressure ulcers and prevent worsening of the pressure ulcers for one (1) of fourteen (14) sampled residents (Resident #1). On [DATE], Resident #1 returned from the hospital with an unstageable pressure injury to the sacrum that worsened. Record review revealed there were no revisions made to the comprehensive care plan related to Resident #1's wound or the weekly changes in the wounds condition. […]

• Immediate jeopardy, isolatedF686Aug 5, 2022

  Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure residents' wounds were assessed and residents received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of fourteen (14) sampled residents (Resident #1). On [DATE], Resident #1 returned from the hospital with an unstageable pressure injury to the sacrum that worsened. Review of Wound Notes documentation, dated [DATE], revealed Resident #1 had an unstageable pressure injury to the sacrum measuring three point five by two by zero-point three (3.5 x 2.0 x 0.3) centimeters (cm). […]

• No harm, potential for more than minimal, widespreadF812May 8, 2025

  Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 50 of the facility's 50 residents who consumed food from the kitchen. The findings include: Review of the facility's policy titled, Food Receiving and Storage, revision dated ,d+[DATE], revealed dry foods that were stored in bins were removed from original packaging, labeled and dated (use bydate) and were rotated using a first in--first out system. Continued review revealed all foods stored in the refrigerator or freezer were covered, labeled and dated (use by date). […]

• No harm, potential for more than minimal, widespreadF804Mar 21, 2024

  Based on observation and interview, it was determined the facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for the lunch meal served on 03/19/2024. The findings include: Review of the facility's policy titled, Food Temperatures, not dated, revealed foods would be served at proper temperatures to ensure food safety and palatability. Continued review revealed that acceptable serving temperatures for meat entrees were to be greater than 140 degrees Fahrenheit but preferred between 140 and 165 degrees Fahrenheit . Review of the posted menu for the noon meal on 03/19/2024, revealed the following items: baked glazed ham, broccoli and cheese, frosted chocolate cake, and cornbread. […]

• No harm, potential for more than minimal, widespreadF880Mar 21, 2024

  Based on observation, interview and review of facility policy it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 21 sampled residents. (Resident #25, #39, #41, #47, #50 and #54) and 4 unsampled residents (Resident #64, #65 #66 and #67). The findings include: Review of the facility's policy titled, Policies and Practices - Infection Control, revealed the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. […]